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Illicit drug use is a major health issue worldwide. Annually,
approximately 250 million individuals are involved in drug use,
with up to 21 million using injection drugs.1 In
2008, an estimated 20.1 million Americans ≥12 years of age used
an illicit drug within the previous month, and of these, 213,000
used heroin, nearly twice the prevalence rate of 2005.2 Between
1996 and 2006, heroin-related ED visits more than doubled (from
73,846 to 189,780), with the majority of visits made by men (69%) and
patients aged 35 to 44 years.2

The practice of injection drug use, and the lifestyle and culture
of the injection drug user, place the individual at risk for a wide
variety of infectious and noninfectious medical complications. In
addition to carrying an increased risk of human immunodeficiency
virus (HIV) infection, hepatitis, tetanus, and sexually transmitted
diseases, the injection drug user’s lifestyle is also associated
with an increased risk of trauma and intimate partner violence.3 The
high incidence of migration, incarceration, homelessness, nutritional
deficiencies, coincident smoking and alcohol use, and mental illness
further compromise this population’s health.4

The sale of drugs and participation in commercial street sex
work to generate illegal income, and the exchange of sex for drugs
further complicates the lives of these individuals and produces
medical complications that lead them to seek care. Many enter the
industry to maintain expensive drug habits. Drugs may be supplied
to a sex worker by the handler (pimp) in exchange for earnings.
Sex workers are more likely to be exposed to high levels of violence
and abuse, including beatings, stabbing, rape, robbery, and death,
perpetrated by both clients and handlers. Many of these crimes go
unreported, and information about them may not be volunteered to
health care workers by the victim due to fear of reprisal. Pressure
from clients, depressed judgment when intoxicated, increased likelihood
of exposure to social networks with a high prevalence of sexually
transmitted infection, and competition from other sex workers may
lead these workers to offer, or be coerced into accepting, unprotected
vaginal or anal sex for more money. This behavior places them at
increased risk of acquiring bacterial infections (syphilis, gonorrhea, chlamydial
infections, and mycoplasma infections) and viral infections (HIV
infection; hepatitis A, B, and C; herpes simplex; and human papillomavirus
infection) and their associated long-term sequelae. Vaccination
against hepatitis virus, human papillomavirus, and, when it becomes
available, HIV should be provided to these individuals.5

In addition to placing patients at greater risk for immunomodulating
infections such as HIV infection and hepatitis, injection drug use
itself, including immunomodulation by opiates, has been associated
with immune dysregulation. Exaggerated and atypical lymphocytosis,
diminished lymphocyte responsiveness to mitogenic stimulation and
depressed chemotaxis, hypergammaglobulinemia, increased opsonin production,
decreased T-cell and natural killer cell activity, high levels of circulating
immune complexes, and reticuloendothelial abnormalities have been
found in injection drug users. Because of this immune stimulation,
false positive ...